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SERVICE REQUEST (EH 00 611 Revised 8/23/93 FACILITY ID # co 2 3,/ RECORD ID # �0 2 INVOICE # FACILITY NAME r14-7z7hi� � BILLING PARTY / N SITE ADDRESS AV-069// ( 440— l 77 CITY / ! AIV CA ZIP / OWNER/OPERATOR E7 BILLING PARTY Y / N DBA PHONE #1 ( 0�! ) A,3!2- /P/S` ADDRESS PHONE #2 ( ) CITY STATE ZIP APN # — Land Use Application #1E BOS Dist Location Code CONTRACTOR and/or —--- -- RVICE REQUESTOR BILLING PARTY Y / N DBA PHONE #1 ( ) MAILING ADDRESS FAX # ( ) CITY STATE ZIP BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of some, acknowledge that all site and/or project specific PNS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on Page 1 of this form. 1 also certify that i have prepared this application and that the work to be performed will be done in accor ' 0� 6ff SAN JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. APPLICANT'S SIGNATURE : 5,� `' � 'a`�' A U G 2 U 1996 Title: f///, L7� rZ�� /lel � Date: 443-2-1?-26 SAN JOAOUIN COUNT' � PUBLIC hH�TEpA�L�T�H�pS�ERVICES AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, ope�&p gpfI & IA' f''Gf3�i ;Hb ��I'�IO N. the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as r,2 it is available and at the same time it is provided to me or my representative. Nature of Service Request: Service Code Assigned to Employee # Date Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By EE (/� �6 SUPV ��/ / ACCT OO/ / UNIT CLK ,/ /